197608506-7-14-2022-28-AS-RORN-CHUTMC-20220901145055

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608506
Report Date: 07/14/2022
Date Signed: 07/14/2022 12:11:57 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/28/2022 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20220328134143

FACILITY NAME:	GLEN PARK AT GLENDALE - MARIPOSA ST		FACILITY NUMBER:	197608506
ADMINISTRATOR:	PINK, MARINA		FACILITY TYPE:	740
ADDRESS:	1220 S MARIPOSA ST		TELEPHONE:	(818) 242-9000
CITY:	GLENDALE	STATE: CA	ZIP CODE:	91205
CAPACITY:	120	CENSUS: 72	DATE:	07/14/2022
		UNANNOUNCED	TIME BEGAN:	08:46 AM
MET WITH:	Siranush Aleksanyan - Receptionist		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Resident(s) not being provided their prescriptions as prescribed.
Resident(s) medications not being refilled in a timely manner.
Facility is in disrepair.
Unqualified staff providing residents medications.

INVESTIGATION FINDINGS:

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Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced subsequent complaint investigation visit regarding the above allegation(s). LPA Flores met with Siranush Aleksanyan - Receptionist and explained the reason for the visit.

The investigation consisted of the following: On 4/4/22 LPA Flores requested a copy of staff/resident roster. LPA and assistant administrator tour rooms #20,12,32,29,48,96,90, hallways, and dining room. LPA Flores interviewed residents #1,#2,#3,#4,#5,#6,#7, assistant administrator(S1), and staff #2(S2),#3(S3),#4(S4),#5(S5). LPA Flores reviewed medication for residents #1(R1),#2(R2),#3(R3),#4(R4),#5(R5),#6(R6),#7(R7) and requested copies of medication sheets (MARS) for January, February, March 2022 for R1,R2,R3,R4,R5,R6,R7, training for staff, call logs for physician/pharmacy contacts, contract for roof repairs. On 7/14/22 LPA Flores requested copy of staff/resident roster, Med-Tech notes for March, and delivered findings for the above allegations.

(CONTINUED LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 28-AS-20220328134143

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GLEN PARK AT GLENDALE - MARIPOSA ST	FACILITY NUMBER: 197608506
	VISIT DATE: 07/14/2022

NARRATIVE

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The investigation revealed the following: Regarding allegation: Resident(s) not being provided their prescription as prescribed. It is alleged an unqualified staff was dispensing medication resulting in resident given the wrong medication. Interviews with residents revealed 6 out of 7 residents interview stated that a Med-tech provides the medication to residents and 1 out of 7 residents did not know if staff was trained to provide medication to residents. 4 out of 7 residents stated to have never miss a dose of medication or been given the wrong medication. 2 out of 7 residents stated to have missed a dose of their medication recently, and 1 out of 7 residents stated to "seldom" miss a dose in the past. Interviews with staff revealed 5 out of 5 staff interview stated to not have heard residents state missing medication or of medication errors. On 4/4/22 LPA reviewed medication for R1,R2,R3,R4,R5,R6,R7 which consisted of reviewing the medication sheet which lists all prescribed and PRN medication and comparing it to the bubble packs or medication bottles, checking initials marked on dates for medication provided by Med-Tech and ensuring the medications listed are available. No errors were observed.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Regarding allegation: Resident(s) medications not being refilled in a timely manner. It is alleged staff did not have nor had requested residents medications prior to running out. Interviews with residents revealed 4 out of 7 residents have always have their prescription available and filled, 2 out of 7 residents stated to either their prescription not filled timely or had been missing at the time of providing dose, and 1 out of 7 residents stated their social worker ensures prescription is filled. Interviews with staff revealed 3 out of 5 staff stated to not have heard of prescription not available at facility, 2 out of 5 staff stated resident had complaint of not having prescription available or prescription was not filled timely, however the prescription was not filled due to change of pharmacy by resident. 1 out of 5 staff interview stated that the pharmacy did not filled a prescription for resident due to communication between the physician and the pharmacy, and facility reach out to assist with getting the prescription filled out. Documents review revealed medication sheet noted a medication had finished on 2/25/22 and 3/27/22 for R7 and there were (0) zero refills available, a fax communication transcript was reviewed dated 2/14/22 regarding requesting refill to a different pharmacy and Med-tech notes regarding same medication for March 25th and 26th showed staff noted a follow up with physician for refill of medication.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, (CONTINUED ON LIC 9099C)

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 28-AS-20220328134143

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GLEN PARK AT GLENDALE - MARIPOSA ST	FACILITY NUMBER: 197608506
	VISIT DATE: 07/14/2022

NARRATIVE

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therefore the allegation is UNSUBSTANTIATED.

Regarding allegation: Facility is in disrepair. It is alleged that rooms #19, #21, the hallways and the dining room have water leaks. On 4/4/22 LPA conducted a facility tour and observed no leaks or ceiling water stains throughout the facility. In room #29 LPA observed a repair patch around the fan on the ceiling. On 7/14/22 LPA Flores observed room #21 and did not observed leaks. Interviews with residents revealed 4 out of 7 residents revealed that no leaks were observed at the facility and 3 out of 7 residents interview stated to have observed leaks throughout the facility when it rains. Interviews with staff revealed 4 out of 5 staff stated to have observed leaks throughout the facility and 1 out of 5 staff interview stated to have not observed leaks throughout the facility. Documents reviewed revealed facility has a Contract Agreement - Proposal dated: 1/7/22 with Pro Roofing Co. with an estimated starting date of: 3/18/22 and estimated completion date of: 4/8/22 for facility area to be re-roof of: entire roof. Per administrator the contractors met the completion date. Maintenance Request Order forms between January and March 2022 note toilet overflow water repairs only. Two (2) Internal Incident Reports dated: 12/25/21 - Location room #21 revealed the following, first report shows housekeeper reported to management regarding leak in room #21, Reason for Review date and reviewed by: on 12/21/21 and initialed noted "recommended resident to move room to get room fixed". Second report note on Reason for review - date and reviewed by: on 12/27/21 no initials notes resident was "recommended to move room temporarily" resident answered "No".

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Regarding allegation: Unqualified staff providing residents medications. It is alleged that there have been several times unqualified staff have provided residents the wrong medications. Interviews with residents revealed 6 out of 7 residents interview stated Med-Tech passes out the medication and 1 out of 7 residents stated to not know if the staff is trained to pass out medication. Interviews with staff revealed 5 out of 5 staff stated the Med-Tech passes out the medication to the residents. Documents reviewed revealed 2 out of the 5 staff interviewed have a Certificate of Completion on Medication Training completing shadow training, didactic, and written exam S2 completed training on 2/24/22 and S3 completed training on 5/5/21. On 4/4/22 LPA reviewed medication for R1,R2,R3,R4,R5,R6,R7 which consisted of reviewing the medication sheet which lists all prescribed and PRN medication and comparing it to the bubble packs or medication bottles, checking initials (CONTINUED LIC 9099C)

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 28-AS-20220328134143

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GLEN PARK AT GLENDALE - MARIPOSA ST	FACILITY NUMBER: 197608506
	VISIT DATE: 07/14/2022

NARRATIVE

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marked on dates for medication provided by Med-Tech and ensuring the medications listed are available.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview was conducted with Marina Pink Administrator and Rachel De Chavez Assistant Administrator and a copy of this report was provided.

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022

LIC9099 (FAS) - (06/04)

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